Extended robot-assisted laparoscopic prostatectomy and extended pelvic lymph node dissection as a monotherapy in patients with very high-risk prostate cancer Patients

Transcriptomic miRNA and mRNA signatures in primary prostate cancer that are associated with lymph-node invasion

BACKGROUND

Nomograms or comparable techniques can be used to determine which patients with prostate cancer (PCa) will benefit from extended pelvic lymph node dissection (ePLND). While nomograms help guide clinical decisions, ∼80% of the patients undergo unnecessary ePLND. This pilot study aims to identify both transcriptomic mRNA and microRNA (miR) signatures in primary PCa tumours that are associated with the presence of lymph node metastasis (LNM).

METHODS

Primary PCa tumours obtained from 88 patients (pathologically diagnosed as N0 [pN0, n = 44] or as N1 [pN1, n = 44]) were profiled using two different probe-based captured direct assays based on next-generation sequencing and targeting 19398 mRNA transcripts (human transcriptome panel [HTP] dataset) and 2083 miRs (miRs whole-transcriptome assay [WTA] dataset). The TCGA-PRAD (pN0 [n = 382] and pN1 [n = 70]) and GSE220095 (pN0 [n = 138] and pN1 [n = 17]) datasets were used for validation using bioinformatic analyses.

RESULTS

A four-mRNA signature (CHRNA2, NPR3, VGLL3 and PAH) was found in primary tumour tissue samples from pN1 PCa patients, and then it was validated using the TCGA-PRAD and GSE220095 datasets. Adding serum prostate-specific antigen (PSA) values to the four-gene signature increased the performance to identify pN1 (HTP [AUC = .8487, p = 2.18e-09], TCGA-PRAD [AUC = .7150, p = 8.66e-08] and GSE220095 datasets [AUC = .8772, p = 4.09e-07]). Paired miR analyses showed that eight miRs were significantly upregulated in primary PCa that were pN1 (p < .01). The eight-miR signature performance increased when adding PSA (WTA dataset [AUC = .8626, p = 4.66e-10]) or Grade group (WTA dataset [AUC = .8689, p = 2e-10]). When combining the miR/mRNA signatures (miR-663b, CHRNA2 and PAH) with PSA levels, it showed the best performance to distinguish pN1 from pN0 PCa patients.

CONCLUSION

This study found miR/mRNA signatures in primary PCa tumours that in combination with serum PSA levels may complement nomograms for better detection of PCa patients with LNM and triage patients into better surgical decision-making.

KEY POINTS

Primary prostate cancer (PCa) tumours from patients pathologically diagnosed as N0 (pN0) or N1 (pN1) were dually assessed for microRNA (miRs) and mRNA levels using an NGS-based assay. A four-mRNA and an eight-miRNA signature were found. The mRNA signatures were further validated using two datasets. The combination of serum prostate-specific antigen (PSA) levels or Grade Group with the miR/mRNA signatures separates pN1 from pN0 PCa patients.

Advanced age is an independent prognostic factor of disease progression in high-risk prostate cancer: results in 180 patients treated with robot-assisted radical prostatectomy and extended pelvic lymph node dissection in a tertiary referral center

OBJECTIVES

This study aimed to assess more clinical and pathological factors associated with prostate cancer (PCa) progression in high-risk PCa patients treated primarily with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND) in a tertiary referral center.

MATERIALS AND METHODS

In a period ranging from January 2013 to October 2020, RARP and ePLND were performed on 180 high-risk patients at Azienda Ospedaliera Universitaria Integrata of Verona (Italy). PCa progression was defined as biochemical recurrence/persistence and/or local recurrence and/or distant metastases. Statistical methods evaluated study endpoints, including Cox's proportional hazards, Kaplan-Meyer survival curves, and binomial logistic regression models.

RESULTS

The median age of included patients was 66.5 [62-71] years. Disease progression occurred in 55 patients (30.6%), who were more likely to have advanced age, palpable tumors, and unfavorable pathologic features, including high tumor grade, stage, and pelvic lymph node invasion (PLNI). On multivariate analysis, PCa progression was predicted by advanced age (≥ 70 years) (HR = 2.183; 95% CI = 1.089-4377, p = 0.028), palpable tumors (HR = 3.113; 95% CI = 1.499-6.465), p = 0.002), and PLNI (HR = 2.945; 95% CI = 1.441-6.018, p = 0.003), which were associated with clinical standard factors defining high-risk PCa. Age had a negative prognostic impact on elderly patients, who were less likely to have palpable tumors but more likely to have high-grade tumors.

CONCLUSIONS

High-risk PCa progression was independently predicted by advanced age, palpable tumors, and PLNI, which is associated with standard clinical prognostic factors. Consequently, with increasing age, the prognosis is worse in elderly patients, who represent an unfavorable age group that needs extensive counseling for appropriate and personalized management decisions.

The survival benefit of different lymph node yields in radical prostatectomy for pN1M0 prostate cancer patients: Implications from a population-based study

Background and objectives

The extent and survival benefits of lymph node dissection (LND) in radical prostatectomy (RP) for pN1M0 prostate cancer (PCa) patients remained unclear and were controversial. This study aimed to determine the survival benefit of different lymph node yields in RP for pN1M0 PCa patients.

Methods

pN1M0 PCa patients who received RP and LND were identified in Surveillance Epidemiology and End Results (SEER) (2010–2015). Patients were divided into two groups in SEER based on the removal of one to three regional lymph nodes (LND1 group) or four or more regional lymph nodes (LND4 group). Kaplan–Meier methods were used to calculate cancer-specific survival (CSS) and overall survival (OS).

Results

In total, 2,200 patients were identified; 264 patients received LND1 and 1,936 patients received LND4. CSS had no significant difference between the LND4 and LND1 groups (101mon vs. 98mon, p = 0.064), and OS was higher in LND4 patients compared with LND1 patients (97mon vs. 93mon, p = 0.024); for patients with Gleason score = 9 or 10 and T3b or T4, 5-year OS was higher in patients undergoing LND4 (80.9%; 95% CI, 79.0–82.8) compared with those undergoing LND1 (67.5%; 95% CI, 60.8–74.2) (p = 0.009).

Conclusion

More lymph node yield provided better survival for patients with Gleason score = 9 or 10 and T3b or T4, but not for other pN1M0 PCa patients. The extent of LND would be determined after a comprehensive evaluation including Gleason score, tumor stage, and the general condition of the patient.

Extended robot-assisted laparoscopic prostatectomy and extended pelvic lymph node dissection as a monotherapy in patients with very high-risk prostate cancer Patients

Background

Patients with very‐high‐risk prostate cancer (VHRPCa) have earlier biochemical recurrences (BCRs) and higher mortality rates. It remains unknown whether extended robot‐assisted laparoscopic prostatectomy (eRALP) without neoadjuvant or adjuvant therapy can improve the outcomes of VHRPCa patients. We aimed to determine the feasibility and efficacy of eRALP as a form of monotherapy for VHRPCa.

Methods

Data from 76 men who were treated with eRALP without neoadjuvant/adjuvant therapy were analyzed. eRALP was performed using an extrafascial approach. Extended pelvic lymph node (LN) dissection (ePLND) included nodes above the external iliac axis, in the obturator fossa, and around the internal iliac artery up to the ureter. The outcome measures were BCR, treatment failure (defined as when the prostate‐specific antigen level did not decrease to <0.1 ng/ml postoperatively), and urinary continence (UC). Kaplan–Meier, logistic regression, and Cox proportional‐hazards model were used to analyze the data.

Results

The median operative time was 246 min, and median blood loss was 50 ml. Twenty‐one patients experienced postoperative complications. Median follow‐up was 25.2 months; 19.7% of patients had treatment failure. Three‐year, BCR‐free survival rate was 62.0%. Castration‐resistant prostate cancer‐free survival rate was 86.1%. Overall survival was 100%. In 55 patients who had complete postoperative UC data, 47 patients (85.5%) recovered from their UC within 12 months. Clinical stage cT3b was an independent preoperative treatment failure predictor (p = 0.035), and node positivity was an independent BCR predictor (p = 0.037). The small sample size and retrospective nature limited the study.

Conclusions

This approach was safe and produced acceptable UC‐recovery rates. Preoperative seminal vesicle invasion is associated with treatment failure, and pathological LN metastases are associated with BCR. Therefore, our results may help informed decisions about neoadjuvant or adjuvant therapies in VHRPCa cases.

Precis

Extended robot‐assisted laparoscopic prostatectomy and extended pelvic lymph node dissection without adjuvant therapy is safe and effective for some patients with very‐high‐risk prostate cancer. The clinical stage and node positivity status predicted monotherapy failure, which may indicate good adjuvant therapy candidate.